Let’s say you are going to review a nursing home medical record in your Professional Legal Nurse Consultant (PLNC) practice, so you are wondering what issues you might face. While each case is unique and has it’s own issues, you will likely come across these three negligence issues at some point. Whether you are reviewing the chart for the plaintiff or defendant, be sure you address each one separately.
1. Pressure ulcers: Commonly called bedsores, decubitus or decubitus ulcers. The immobility of this population, unfortunately, is one of many causes for the formation of pressure ulcers. In your PLNC clinical review, you will need to address this issue. When did the pressure ulcer start? What is the stage or is it unstageable? What, exactly, is the treatment protocol and what does the documentation show? Are there photographs? Was the resident identified as being at high risk for pressure ulcer development? Was the physician/nurse practitioner on notice?
2. Falls: Residents are usually thoroughly assessed at admission. Was the treatment plan updated to reflect any falls? What interventions were put into place? Is the family “on-board” with the treatment plan?
3. Malnutrition: Perhaps it might be under nutrition or dehydration. Does the medical record have updated dietitian assessments and interventions? Is the resident on a special diet? Is there documentation of the percentage, or amount, of consumption?
Thoroughly review the medical records. Then, think about these three potential injuries and be sure you address them in your Professional Legal Nurse Consultant report.
